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Bi X, Yu Y, Zhou S, Zhou Y, Zhao J, Xiong J. Immunosuppressant Agents as Add-On Therapy Failed to Improve the Outcome of Immunoglobulin A Nephropathy with Crescent Score C1. Nephron Clin Pract 2024:1-14. [PMID: 38723614 DOI: 10.1159/000534788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/11/2023] [Indexed: 06/19/2024] Open
Abstract
INTRODUCTION The renoprotective benefits of adding immunosuppressant therapy to corticosteroid (CS) treatment for immunoglobulin A nephropathy (IgAN) patients with less than 25% crescent formation (C1) remain uncertain, warranting further research. METHODS A retrospective study was conducted on IgAN patients with crescent C1 lesions confirmed by renal biopsy at Xinqiao Hospital between May 1, 2017, and May 1, 2020. Patients were stratified into either the CS treatment group or the CS combined with an additional immunosuppressant therapy group. Follow-up assessments were conducted within 24 months. Propensity score analysis was used to match patients receiving CS and CS + immunosuppressant drug treatment in a 1:1 ratio. Primary outcomes included changes in estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR). Subgroup analyses were performed to evaluate the benefits of different populations. Composite endpoint outcomes comprised a 30% eGFR decrease, end-stage kidney disease (ESKD) necessitating dialysis or transplant, or kidney disease-related mortality. Adverse events were also compared between the two groups. RESULTS 296 IgAN patients with C1 lesions were included in the analysis. Baseline characteristics indicated that IgAN patients in the CS + immunosuppressant group exhibited poorer renal function and higher UACR levels. Propensity score analysis effectively minimized the influence of baseline clinical characteristics, including age, serum creatinine, initial eGFR, UACR, and 24-h proteinuria. Both treatment groups demonstrated continuous eGFR improvement and significant UACR reduction during follow-up, especially at 6 months. However, no significant differences in eGFR and UACR reduction rates were observed between the two groups throughout the entire follow-up period, both before and after matching. Subgroup analysis revealed improved eGFR in both treatment groups, notably among patients with an initial eGFR below 90 mL/min/1.73 m2. Conversely, IgAN patients with C1 lesions and a cellular crescent ratio exceeding 50% treated with CS and immunosuppressant therapy experienced a significant improvement in renal function and a decline in urinary protein creatinine ratio. Composite endpoint outcomes did not significantly differ between the two groups, while the incidence of adverse events was comparable. CONCLUSION Our findings suggest that the addition of immunosuppressant therapy to corticosteroid monotherapy did not confer significant therapeutic advantages in patients with C1 lesions compared to CS monotherapy, although some specific patient populations appeared to derive modest benefits from this combined approach.
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Affiliation(s)
- Xianjin Bi
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Cardiovasology, People's Liberation Army Joint Logistic Support Force 945th Hospital, Yaan, China
| | - Yanlin Yu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Siyan Zhou
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yue Zhou
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jinghong Zhao
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiachuan Xiong
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Barr B, Barbour S. New therapies for immunoglobulin A nephropathy: what's the standard of care in 2023? Curr Opin Nephrol Hypertens 2024; 33:311-317. [PMID: 38411173 DOI: 10.1097/mnh.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW As the most common primary glomerulonephritis, immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of kidney failure and mortality. Until recently, therapeutic options were limited. Fortunately, there have been numerous recent clinical trials demonstrating efficacy of new therapies in slowing chronic kidney disease (CKD) progression at varying stages of disease. RECENT FINDINGS The TESTING trial has provided high-quality evidence for slowing estimated glomerular filtration rate (eGFR) decline with a reduced-dose glucocorticoid regimen, while demonstrating an improved safety profile. Targeted-release budesonide represents a well tolerated therapy for reducing eGFR decline. Mycophenolate mofetil may reduce CKD progression in some populations, while hydroxychloroquine is efficacious in reducing proteinuria. Sodium-glucose cotransporter (SGLT2) inhibitors and sparsentan are effective therapies for CKD due to IgAN, but should not be used in lieu of disease-modifying immunosuppressive therapy. Many new therapies are approaching readiness for clinical use. SUMMARY Numerous therapeutic options now exist and include disease-modifying and nephroprotective drugs. Identifying the right treatment for the right patient is now the clinical challenge and, with new drugs on the horizon, represents the primary unmet research need in this rapidly-developing field.
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Affiliation(s)
- Bryce Barr
- Section of Nephrology, Department of Medicine, Max Rady College of Medicine, University of Manitoba
| | - Sean Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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Obrișcă B, Mocanu V, Jurubiță R, Vrabie A, Berechet A, Lujinschi Ș, Sorohan B, Andronesi A, Achim C, Lupușoru G, Micu G, Caceaune N, Gherghiceanu M, Ismail G. Histological reappraisal of IgA nephropathy: the role of glomerular pattern of injury and mesangial complement deposition. BMC Nephrol 2024; 25:145. [PMID: 38658875 PMCID: PMC11040743 DOI: 10.1186/s12882-024-03577-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND There is a clear need to refine the histological assessment in IgA Nephropathy (IgAN). We sought to investigate the clinical significance of the light microscopy (LM) pattern of glomerular injury and of the intensity of mesangial C3 staining in IgAN. METHODS We conducted a retrospective, observational study that included all patients with biopsy-proven primary IgAN that had at least 12 months of follow-up. The LM pattern of glomerular injury was reevaluated based on a modified HAAS classification. Mesangial C3 deposition by immunofluorescence (IF) staining was scored semi-quantitatively. The study primary composite endpoint was defined as doubling of serum creatinine or ESRD (dialysis, renal transplant or eGFR < 15 ml/min). The secondary study endpoint was eGFR decline per year. RESULTS This cohort included 214 patients with IgAN (mean age, 41.4 ± 12.6 years), with a mean eGFR and median 24-h proteinuria of 55.2 ± 31.5 ml/min/1.73m2 and 1.5 g/day (IQR:0.8-3.25), respectively. The most frequent LM pattern was the mesangioproliferative (37.4%), followed by the sclerotic (22.5%) and proliferative/necrotizing patterns (21.4%). Regarding the IF findings, mild-moderate and intense mesangial C3 staining was present in 30.6% and 61.1% of patients, respectively. Those with sclerosing and crescentic patterns had the worst renal survival (5-year renal survival of 48.8% and 42.9%) and the highest rate of eGFR change/year (-2.32 ml/min/y and - 2.16 ml/min/y, respectively) compared to those with other glomerular patterns of injury. In addition, those with intense C3 staining reached the composite endpoint more frequently compared to those without intense C3 staining (35.5% vs. 21.4%, p = 0.04). After multivariate adjustment, patients with crescentic and sclerosing patterns had a 3.6-fold and 2.1-fold higher risk for the composite endpoint compared to those with mesangioproliferative pattern, while an intense mesangial C3 deposition being also associated with a worse renal outcome (HR, 3.33; 95%CI, 1.21-9.2). CONCLUSIONS We have shown that the LM pattern of glomerular injury and the intensity of mesangial C3 deposition might stratify more accurately the renal outcome in patients with IgAN.
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Affiliation(s)
- Bogdan Obrișcă
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.
| | - Valentin Mocanu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Roxana Jurubiță
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandra Vrabie
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Berechet
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Ștefan Lujinschi
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Bogdan Sorohan
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Andronesi
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Camelia Achim
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriela Lupușoru
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Georgia Micu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicu Caceaune
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Mihaela Gherghiceanu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Gener Ismail
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
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Trimarchi H, Fervenza FC, Coppo R. Points of view in nephrology: personalized management of IgA nephropathy, beyond KDIGO. J Nephrol 2024; 37:739-745. [PMID: 38236471 DOI: 10.1007/s40620-023-01833-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
IgA nephropathy is the most common primary glomerulonephritis worldwide, and an important cause of kidney failure, as 20-40% of patients progress to renal replacement therapy 20-30 years after diagnosis. Its clinical presentation ranges from isolated microscopic hematuria to nephrotic syndrome, and even to a rapidly progressive course. Ethnicity and epigenetics play a key role in its clinical aggressiveness. Selection of patients at risk needing immunosuppressive treatment is a challenge for the nephrologist. Some active and chronic kidney lesions detected on kidney biopsy have been demonstrated to have prognostic value according to the Oxford Classification of IgA nephropathy, later validated by numerous studies. However, KDIGO 2021 guidelines still consider persistent proteinuria > 1 g/24 h to be the most relevant risk factor for the progression of IgA nephropathy and the only one requiring immunosuppressive treatment. KDIGO guidelines have proposed a therapeutic algorithm, but many patients present peculiar characteristics that are not addressed by the current guidelines, pointing to the need for alternative approaches. In these cases, a tailored approach to each patient should be followed in which clinical, histological, laboratory, social and ethical aspects must be considered. In this manuscript we present three cases of IgA nephropathy from different countries, highlighting many of the aspects encountered in clinical practice that illustrate an individualized approach to the treatment of these patients.
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Affiliation(s)
- Hernán Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | | | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.
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Ma S, Jiang Y, Qian L, Wang M, Xu S, Wang G. Efficacy of traditional Chinese medicine versus angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and their combinations in the treatment of IgA nephropathy: a systematic review and network meta-analysis. Front Pharmacol 2024; 15:1374377. [PMID: 38576485 PMCID: PMC10991836 DOI: 10.3389/fphar.2024.1374377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/07/2024] [Indexed: 04/06/2024] Open
Abstract
Background IgA nephropathy (IgAN), a condition posing a significant threat to public health, currently lacks a specific treatment protocol. Research has underscored the potential benefits of traditional Chinese medicine (TCM) for treating IgAN. Nevertheless, the effectiveness of various intervention strategies, such as combining TCM with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), lacks a comprehensive systematic comparison. Therefore, this study aimed to conduct a network meta-analysis to assess the clinical efficacy of ACEIs, ARBs, TCM, and their combinations in treating IgAN to offer novel insights and approaches for the clinical management of IgAN. Methods A systematic review conducted until November 2023 included relevant literature from databases such as PubMed, Embase, Cochrane, Web of Science, Scopus, CNKI, and Wanfang. Two independent researchers screened and assessed the data for quality. Network and traditional meta-analyses were performed using Stata 18.0 and RevMan 5.3 software, respectively. Outcome measures included 24-h urinary protein quantification (24 hpro), estimated glomerular filtration rate (eGFR), serum creatinine (Scr), blood urea nitrogen (BUN), and adverse event incidence rates (ADRs). Forest plots, cumulative ranking probability curves (SUCRA), and funnel plots generated using Stata 18.0 facilitated a comprehensive analysis of intervention strategies' efficacy and safety. Results This study included 72 randomized controlled trials, seven interventions, and 7,030 patients. Comparative analysis revealed that ACEI + TCM, ARB + TCM combination therapy, and TCM monotherapy significantly reduced the levels of 24 hpro, eGFR, Scr, and BUN compared to other treatment modalities (p < 0.05). TCM monotherapy demonstrated the most favorable efficacy in reducing eGFR levels (SUCRAs: 78%), whereas the combination of ARB + TCM reduced Scr, 24 hpro, and BUN levels (SUCRAs: 85.7%, 95.2%, and 87.6%, respectively), suggesting that ARB + TCM may represent the optimal intervention strategy. No statistically significant differences were observed among the various treatment strategies in terms of ADR (p > 0.05). Conclusion The combination of ACEI or ARB with TCM demonstrated superior efficacy compared to ACEI/ARB monotherapy in the treatment of IgAN without any significant ADRs. Therefore, combination therapies can be used to enhance therapeutic outcomes based on individual patient circumstances, highlighting the use of TCM as a widely applicable approach in clinical practice. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023476674.
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Affiliation(s)
| | | | | | | | - Shijie Xu
- Institute of Basic Theory of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guowei Wang
- Institute of Basic Theory of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
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El Karoui K, Fervenza FC, De Vriese AS. Treatment of IgA Nephropathy: A Rapidly Evolving Field. J Am Soc Nephrol 2024; 35:103-116. [PMID: 37772889 PMCID: PMC10786616 DOI: 10.1681/asn.0000000000000242] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
The pivotal event in the pathophysiology of IgA nephropathy is the binding of circulating IgA-containing immune complexes to mesangial cells, with secondary glomerular and tubulointerstitial inflammation and fibrosis. The paramount difficulty in the management of IgA nephropathy is the heterogeneity in its clinical presentation and prognosis, requiring an individualized treatment approach. Goal-directed supportive care remains the bedrock of therapy for all patients, regardless of risk of progression. Sodium-glucose transporter 2 inhibitors and sparsentan should be integral to contemporary supportive care, particularly in patients with chronic kidney damage. Pending the development of reliable biomarkers, it remains a challenge to identify patients prone to progression due to active disease and most likely to derive a net benefit from immunosuppression. The use of clinical parameters, including the degree of proteinuria, the presence of persistent microscopic hematuria, and the rate of eGFR loss, combined with the mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, crescents score, is currently the best approach. Systemic glucocorticoids are indicated in high-risk patients, but the beneficial effects wane after withdrawal and come at the price of substantial treatment-associated toxicity. Therapies with direct effect on disease pathogenesis are increasingly becoming available. While targeted-release budesonide has garnered the most attention, anti-B-cell strategies and selective complement inhibition will most likely prove their added value. We propose a comprehensive approach that tackles the different targets in the pathophysiology of IgA nephropathy according to their relevance in the individual patient.
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Affiliation(s)
- Khalil El Karoui
- Department of Nephrology, Hôpital Tenon, Sorbonne Université, Paris, France
| | | | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
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Hu Y, Huang Z, Cao Q, Chen B, Xu S, Qiu W, You X, Zhang J, Chen C. Clinical significance of massive proteinuria in primary IgA nephropathy with and without nephrotic syndrome: a single center cohort study. Ren Fail 2023; 45:2267138. [PMID: 37850851 PMCID: PMC10586089 DOI: 10.1080/0886022x.2023.2267138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/01/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Both primary IgA nephropathy (IgAN) with and without nephrotic syndrome (NS) can present massive proteinuria (24-h urinary protein ≥3.5 g/d). The clinical significance of massive proteinuria may be different in the two entities and needs further research. METHODS Data of 1870 patients with biopsy-proven IgAN in our hospital from January 2011 to December 2022 was retrospectively reviewed. A total of 242 IgAN patients with massive proteinuria were enrolled. Patients who presented with nephrotic syndrome at renal biopsy were included in the IgAN with NS cohort (IgAN-NS). The IgAN with nephrotic-range proteinuria cohort (IgAN-NR) consisted of 1:1 matched cases from the remaining according to age, gender, estimated glomerular filtration rate (eGFR) at baseline, and follow-up time. The clinical and pathological characteristics between the two cohorts were analyzed. RESULTS The IgAN-NS had a significantly higher proteinuria level than the IgAN-NR (p < .001). Cluster analysis revealed that proteinuria was associated with lipids in IgAN-NS, while it was associated with inflammatory indicators in IgAN-NR. When the complete remission of proteinuria (CR) was not achieved, the Kaplan-Meier analysis showed the prognosis of IgAN-NS was significantly worse than that of IgAN-NR (p = .04). Then, our GLMM model and line chart showed that the serum albumin level of the IgAN-NR was always evidently higher than that of the IgAN-NS while the significant difference in urinary albumin/creatinine ratio between the two cohorts gradually disappeared during the short-term follow-up (1 year). Moreover, the Cox regression analysis showed that the increased serum albumin was an independent protective factor for the poor outcomes (eGFR decreased from the baseline ≥ 30% continuously or reached end-stage renal disease [ESRD]). CONCLUSION The IgAN-NS had poorer clinicopathologic manifestation than IgAN-NR, including severer massive proteinuria. When the CR was not achieved, the prognosis of IgAN-NS was inferior to that of the IgAN-NR.
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Affiliation(s)
- Ya Hu
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Ziyuan Huang
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Qianqian Cao
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Bo Chen
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Shungang Xu
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Wenxian Qiu
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Xiaohan You
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Ji Zhang
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Chaosheng Chen
- Department of Nephrology, The First Affifiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
- Institute of Chronic Kidney Disease, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
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Aiello FB, Ranelletti FO, Liberatore M, Felaco P, De Luca G, Lamolinara A, Schena FP, Bonomini M. Independent Prognostic and Predictive Role of Interstitial Macrophages in Kidney Biopsies of IgA Nephropathy Patients. J Pers Med 2023; 13:935. [PMID: 37373924 DOI: 10.3390/jpm13060935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
A relevant percentage of IgAN patients experience a progressive decline in kidney function. According to the KDIGO guidelines, proteinuria and eGFR are the only validated prognostic markers. The role of interstitial macrophages in kidney biopsies of IgAN patients and the outcome of patients treated with renin-angiotensin system inhibitors (RASBs) alone or combined with glucocorticoids were evaluated. Clinical and laboratory records (age, gender, hypertension, hematuria, proteinuria, eGFR, serum creatinine, and therapy), MEST-C parameters of the Oxford classification, C4d deposition, peritubular capillaries, and glomerular and interstitial macrophages in 47 IgAN patients undergoing kidney biopsy consecutively between 2003 and 2016 were examined. A high number of interstitial macrophages significantly correlated with peritubular capillary rarefaction and impairment of kidney function. Cox's multivariable regression analysis revealed that a value > 19.5 macrophages/HPF behaved as an independent marker of an unfavorable outcome. Patients exhibiting > 19.5 macrophages/HPF treated at the time of diagnosis with RASBs combined with methylprednisolone had an estimated probability of a favorable outcome higher than patients treated with RASBs alone. Thus, a value > 19.5 macrophages/HPF in IgAN biopsies can predict an unfavorable outcome and endorse a well-timed administration of glucocorticoids. Studies evaluating urine biomarkers associated with peritubular capillary rarefaction in patients with marked macrophage infiltration may help personalized treatment decisions.
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Affiliation(s)
- Francesca Bianca Aiello
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti-Pescara, 66100 Chieti, Italy
| | | | | | - Paolo Felaco
- UOC Nephrology and Dialysis PO, 64100 Teramo, Italy
| | - Graziano De Luca
- Graziano De Luca UO Clinical Pathology, Val Vibrata Hospital, 64027 Sant'Omero, Italy
| | - Alessia Lamolinara
- Department of Neurosciences, Imaging and Clinical Sciences, University G. D'Annunzio, Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Paolo Schena
- Department of Emergency and Organ Transplantation, University of Bari, 70121 Bari, Italy
- Schena Foundation, Valenzano, 70010 Bari, Italy
| | - Mario Bonomini
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti-Pescara, 66100 Chieti, Italy
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Abstract
Chronic kidney disease (CKD) is a worldwide public health issue and has ultimately progressed to an end-stage renal disease that requires life-long dialysis or renal transplantation. However, the underlying molecular mechanism of these pathological development and progression remains to be fully understood. The human gut microbiota is made up of approximately 100 trillion microbial cells including anaerobic and aerobic species. In recent years, more and more evidence has indicated a clear association between dysbiosis of gut microbiota and CKD including immunoglobulin A (IgA) nephropathy, diabetic kidney disease, membranous nephropathy, chronic renal failure and end-stage renal disease. The current review describes gut microbial dysbiosis and metabolites in patients with CKD thus helping to understand human disease. Treatment with prebiotics, probiotics and natural products can attenuate CKD through improving dysbiosis of gut microbiota, indicating a novel intervention strategy in patients with CKD. This review also discusses therapeutic options, such as prebiotics, probiotics and natural products, for targeting dysbiosis of gut microbiota in patients to provide more specific concept-driven therapy strategy for CKD treatment.
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Affiliation(s)
- Ying-Yong Zhao
- Faculty of Life Science & Medicine, Northwest University, Xi’an 710069, Shaanxi, China
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Xu RC, Guo JY, Cao T, Xu Y, Liao Y, Chen YN, Song HY, Chen XJ, Guan MJ, Tang F, Xiang Q, Chen XL, Wan QJ. A mixed-method evaluation of the relationship between Oxford classification scores and longitudinal changes in proteinuria in patients with immunoglobulin A nephropathy. Front Endocrinol (Lausanne) 2022; 13:890900. [PMID: 36704031 PMCID: PMC9871483 DOI: 10.3389/fendo.2022.890900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/25/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the relationship between Oxford Classification scores and longitudinal changes in proteinuria in patients with immunoglobulin A nephropathy (IgAN). METHODS The study was a single-center retrospective cohort study involving 358 patients with primary IgAN who were treated at the Shenzhen Second People's Hospital, China, between January 2011 and May 2021. Multivariate linear regression and generalized additive mixed models (GAMMs), adjusted for traditional risk confounders, were used to evaluate the correlation between scores for mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental glomerulosclerosis (S), tubular atrophy/interstitial fibrosis (T), and crescents (C) (known as the Oxford Classification MEST-C score system), with proteinuria/creatinine ratio (PCR) at the time of renal biopsy and longitudinal changes in PCR, respectively. RESULTS The median PCR was 1061 mg/g, and it increased on average by 68.82 mg/g per year in these patients. Among patients with renal insufficiency, compared with patients without relative lesions, those with E present (E1) (1153.44; 95% confidence interval [CI], 188.99-2117.89 mg/g) and C > 0 (C1/2) (1063.58; 95% CI, 185.25-1941.90 mg/g) were associated with increased PCR levels at the time of renal biopsy. What's more, S present (S1) (194.96; 95% CI, 54.50-335.43 mg/g per year) was associated with the fastest PCR increase; C > 0 (C1/2) (147.59; 95% CI, 8.32-286.86 mg/g per year) and T >25% (T1/2) (77.04; 95% CI, 7.18-146.89 mg/g per year), were also correlated with a faster PCR increase. In patients with normal kidney function, associations between S1 (55.46; 95% CI, 8.93-101.99 mg/g per year) and E1 (94.02; 95% CI, 21.47-166.58 mg/g per year) and PCR change could be observed. Additionally, in patients with overweight/obesity, S1 (156.09; 95% CI, 52.41-259.77 mg/g per year), E1 (143.34; 95% CI, 35.30-251.38 mg/g per year), T1/2 (116.04; 95% CI, 22.58-209.51 mg/g per year), as well as C1/2 (134.03; 95% CI, 41.73-226.32 mg/g per year) were associated with noticeably quicker PCR increase. CONCLUSIONS Overall, E1 and C1/2 were independently associated with raised proteinuria levels at the time of renal biopsy, and S1, E1, T1/2, C1/2 were independently associated with a longitudinal increase in proteinuria in the patients with IgAN, especially in those with renal insufficiency or overweight/obesity, suggesting that currently available treatments might not be satisfactory, and weight control might be beneficial. Individual therapy development might benefit from the use of the Oxford Classification system.
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Affiliation(s)
- Ri-Cong Xu
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Jian-Ying Guo
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Tao Cao
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Yi Xu
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Ying Liao
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Yu-Na Chen
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Hai-Ying Song
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Xiao-Jie Chen
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Mi-Jie Guan
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Fei Tang
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Qiong Xiang
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
| | - Xing-Lin Chen
- Department of Epidemiology and Biostatistics, Empower U, X&Y solutions Inc., Boston, MA, United States
| | - Qi-Jun Wan
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Nephrology, The Second People's Hospital of Shenzhen, Shenzhen, China
- *Correspondence: Qi-Jun Wan,
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Jia Q, Ma F, Yang X, Li L, Liu C, Sun R, Li R, Sun S. Long-term outcomes of IgA nephropathy patients with less than 25% crescents and mild proteinuria. Clin Exp Nephrol 2021; 26:257-265. [PMID: 34724588 DOI: 10.1007/s10157-021-02154-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whether immunosuppressive therapy in IgA nephropathy (IgAN) patients with less than 25% crescents (C1) and mild proteinuria can improve the renal outcome is still unclear. METHODS We recruited 140 IgAN patients with C1 and proteinuria < 1 g/24 h who received supportive care (n = 52) or steroid-based immunosuppressive therapy (n = 88) in Xijing Hospital from July 2008 to December 2016. The primary outcome was the rate of renal function decline. RESULTS The median of proteinuria was 575.5 mg/24 h, the fraction of crescents was 7% (5%, 12%) and follow-up time was 69.1 months. The rate of renal function decline [0.5 (- 1.5, 3.2) vs - 0.7 (- 3.5, 0.5) ml/min per 1.73 m2 per year; P = 0.01] was slower in steroid-based immunosuppressive therapy group than supportive care group. Multivariate linear regression analyses showed steroid-based immunosuppressive therapy significantly slowed down the rate of renal function decline (β = - 0.220, 95% CI - 3.804 to - 0.449, P = 0.013) after adjusting age, sex, MAP, proteinuria, eGFR, M1, E1, S1, T1-2, the fraction of crescents and RASB. In the matched cohort, the rate of renal function decline was also slower in steroid-based immunosuppressive therapy group. The incidence of adverse events was similar between the two groups. CONCLUSION Steroid-based immunosuppressive therapy may slow down the rate of renal function decline of IgAN patients with C1 and proteinuria ≤ 1 g/24 h.
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Affiliation(s)
- Qing Jia
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China. .,Xi'an Jiao Tong University-Affiliated Honghui Hospital, Xi'an, 710054, Shaanxi, China.
| | - Xiaoxia Yang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Linlin Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Chunmei Liu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Ruiling Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Rong Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi Province, China.
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12
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Guo Y, Shi S, Zhou X, Liu L, Lv J, Zhu L, Wang S, Zhang H. The effect of immunosuppressive therapy in patients with fibrinoid necrosis lesions in a large cohort of patients with IgA nephropathy. J Nephrol 2021; 35:1079-1089. [PMID: 34676523 DOI: 10.1007/s40620-021-01176-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Fibrinoid necrosis is considered one of the active pathological lesions in IgA nephropathy. Whether patients with IgA nephropathy with fibrinoid necrosis lesions benefit from immunosuppressive therapy in terms of long-term outcomes remains uncertain. This study aimed to evaluate the response to immunosuppressive therapy in patients with fibrinoid necrosis lesions in a large cohort of patients with IgA nephropathy. METHODS A total of 1325 patients with kidney biopsy-proven IgA nephropathy from 1994 to 2016 were recruited from the Peking University First Hospital IgA Nephropathy Database. The clinicopathological characteristics of patients with fibrinoid necrosis lesions and the effect of immunosuppressive therapy on patients with fibrinoid necrosis lesions alone or in those with fibrinoid necrosis together with crescents or endocapillary hypercellularity lesions were analyzed. RESULTS In total, 107/1325 (8.1%) patients showed fibrinoid necrosis lesions, and 92/107 (86.0%) of these patients showed fibrinoid necrosis associated either with cellular/fibrocellular crescents or endocapillary hypercellularity lesions. The presence of fibrinoid necrosis together with crescents or endocapillary hypercellularity was an independent risk factor for the kidney composite endpoint (HR, 2.11; 95% CI, 1.16-3.84; P = 0.02) in patients without immunosuppression, while for those receiving immunosuppressive therapy, kidney outcome was improved (HR, 0.80; 95% CI, 0.46-1.39; P = 0.42). However, the predictive value of fibrinoid necrosis lesions alone did not change significantly between patients with and without immunosuppressive therapy. CONCLUSIONS The presence of fibrinoid necrosis with crescents or endocapillary hypercellularity lesions together, but not fibrinoid necrosis lesions alone, was a pathological indicator of patients who may benefit from immunosuppressive therapy.
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Affiliation(s)
- Yingman Guo
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China
| | - Sufang Shi
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China.
| | - Xujie Zhou
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China
| | - Lijun Liu
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China
| | - Li Zhu
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China
| | - Suxia Wang
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China.,Electron Microscopy Laboratory, Peking University First Hospital, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Key Laboratory of Renal Disease, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Ministry of Health of China, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, People's Republic of China
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13
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Paranhos RM, De Souza Figueiredo GA, De Abreu GR, Ferreira GC, Fonseca GG, Simões E Silva AC. Immunoglobulin A nephropathy in paediatrics: An up-to-date. Nephrology (Carlton) 2021; 27:307-317. [PMID: 34676611 DOI: 10.1111/nep.13987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/24/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022]
Abstract
Immunoglobulin A nephropathy is the main cause of glomerulonephritis globally and an important aetiology of end-stage renal disease in children. It has been considered an autoimmune disease that can lead to the production of autoantibodies against abnormal IgA1 and formation of immune complexes. These autoantibodies and immune complexes deposit in the glomeruli, resulting in renal injury. At the beginning of IgA nephropathy course, most patients are asymptomatic and the first clinical manifestations in children are macroscopic hematuria and proteinuria. The diagnosis is defined by the detection of IgA mesangial deposits in kidney biopsy using immunofluorescence techniques. The Oxford MEST-C score is the most used classification to associate histological findings and clinical outcomes, being validated for application in children. Recommended treatment options are antihypertensive and antiproteinuric therapy, corticosteroids, immunosuppressive agents, and other non-pharmacological approaches. There is no ideal prognosis indicator but new perspectives are in science's scope to find possible biomarkers of the disease through OMICS's research. This review aims to summarize and to up-to-date the scientific literature on paediatric IgA nephropathy, focusing on pathophysiology, clinical findings, histopathology, current treatment, prognosis, and future perspectives.
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Affiliation(s)
- Rafaela Moreira Paranhos
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Gabriel Augusto De Souza Figueiredo
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Gabriel Ramos De Abreu
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Guilherme Costa Ferreira
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Giulio Gori Fonseca
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Ana Cristina Simões E Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil.,Pediatric Nephrology Unit, Department of Pediatrics, Faculty of Medicine, UFMG, Belo Horizonte, Brazil
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14
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Yang D, Liu H, Peng Y, Fu Y, Chen A, Xu X, Yuan S, Dong Z, Liu Y, Liu H. Clinical implication of the circumferential crescents lesions in immunoglobulin A nephropathy: a single-center study of Han Chinese population. Hum Pathol 2021; 118:49-59. [PMID: 34592241 DOI: 10.1016/j.humpath.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/18/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022]
Abstract
A crescentic lesion in renal biopsy could be segmental or circumferential, but the distribution and clinical implication of the circumferential crescents in immunoglobulin A nephropathy (IgAN) remains unknown. A total of 384 crescentic IgAN patients between 2011 and 2019 were included. The subjects were classified as the circumferential crescent who have at least one crescent involving ≥50% circumference of Bowman's capsule, otherwise as to the segmental crescent. Clinical, pathological, and prognostic relationships were analyzed. The primary endpoint was a 30% decline in eGFR, and the secondary endpoint was more than 3.5 g/d proteinuria during follow-up. Of the 384 patients, 72 (18.8%) patients had more than one circumferential crescent. 52 (17.6%) Oxford C1 patients have circumferential crescent. During a mean follow-up of 32.3 months, both the primary and secondary endpoints have occurred more in the circumferential crescent patients. Kaplan-Meier analysis showed the patient with the circumferential crescent had significantly lower renal survival than those without. In multivariable Cox analyses, having the circumferential crescents in at least one-fifth of glomeruli was independently associated with primary endpoint (hazard ratio:3.60, 95% CI:1.46-8.83), after adjusting for Oxford-score, eGFR, systolic blood pressure, and proteinuria. Furthermore, those patients who scored C1 in Oxford and presenting with circumferential crescents, had better renal survival if they received the other immunosuppressants therapy. The circumferential crescents lesion was associated with adverse outcomes in IgAN, and more than one-fifth of glomeruli circumferential crescents is an independent predictor of 30% eGFR decline after adjusting for clinical and histological parameters.
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Affiliation(s)
- Danyi Yang
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Haiyang Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Youmin Peng
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Ying Fu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Anqun Chen
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Xiangqing Xu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Shuguang Yuan
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Zheng Dong
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood VA Medical Center, Augusta, Georgia 30912, USA.
| | - Yu Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
| | - Hong Liu
- Department of Nephrology, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China; Hunan Key Laboratory of Kidney Disease and Blood, The Second Xiangya Hospital, Central South University, No.139, Renmin Road, Changsha 410011, Hunan Province, PR China.
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Peruzzi L, Coppo R. IgA vasculitis nephritis in children and adults: one or different entities? Pediatr Nephrol 2021; 36:2615-2625. [PMID: 33219450 DOI: 10.1007/s00467-020-04818-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/15/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022]
Abstract
The clinical features of the kidney involvement in immunoglobulin A (IgA) vasculitis (IgAVN) differ in children and adults for both clinical presentation and progression. IgAVN in children has mostly a self-limiting course and favorable resolution, while in adults the kidney involvement is frequently severe with unfavorable outcome. However, a subset of children is at risk of progression within the pediatric age or decades later in adulthood, particularly when the diagnosis and a prompt intervention are delayed. Factors predicting progression and outcome in the whole spectrum of age have been investigated in recent research, as well as the relationship between IgAVN and primary IgAN, which share the same pathology features, in the light of peculiar clinical differences and progression tendencies, and hence need for selective treatments. The search for a personalized treatment in children with IgAV and in different ages of life should rely on the identification of different risks for progression. This review will focus on recent studies which contribute to improve our knowledge in this still largely unclear area.
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Affiliation(s)
- Licia Peruzzi
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.,Pediatric Nephrology Unit, Regina Margherita Department, City of Health and Science University Hospital, Turin, Italy
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.
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16
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Chang M, Yang B, Li L, Si Y, Zhao M, Hao W, Zhao J, Zhang Y. Modified Huangqi Chifeng Decoction Attenuates Proteinuria by Reducing Podocyte Injury in a Rat Model of Immunoglobulin a Nephropathy. Front Pharmacol 2021; 12:714584. [PMID: 34381367 PMCID: PMC8350133 DOI: 10.3389/fphar.2021.714584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/14/2021] [Indexed: 02/05/2023] Open
Abstract
Modified Huangqi Chifeng decoction (MHCD) has been used to reduce proteinuria in immunoglobulin A nephropathy (IgAN) for many years. Previously, we have demonstrated its protective role in glomerular mesangial cells. Podocyte injury, another key factor associated with proteinuria in IgAN, has also attracted increasing attention. However, whether MHCD can reduce proteinuria by protecting podocytes remains unclear. The present study aimed to investigate the protective effects of MHCD against podocyte injury in a rat model of IgAN. To establish the IgAN model, rats were administered bovine serum albumin, carbon tetrachloride, and lipopolysaccharide. MHCD in three doses or telmisartan was administered once daily for 8 weeks (n = 10 rats/group). Rats with IgAN developed proteinuria at week 6, which worsened over time until drug intervention. After drug intervention, MHCD reduced proteinuria and had no effect on liver and kidney function. Furthermore, MHCD alleviated renal pathological lesions, hyperplasia of mesangial cells, mesangial matrix expansion, and podocyte foot process fusion. Western blot analysis revealed that MHCD increased the expression of the podocyte-associated proteins nephrin and podocalyxin. Additionally, we stained podocyte nuclei with an antibody for Wilms’ tumor protein one and found that MHCD increased the podocyte number in rats with IgAN. In conclusion, these results demonstrate that MHCD attenuates proteinuria by reducing podocyte injury.
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Affiliation(s)
- Meiying Chang
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Bin Yang
- Department of Pathology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liusheng Li
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yuan Si
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mingming Zhao
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wei Hao
- Medical Animal Experimental Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinning Zhao
- Medical Animal Experimental Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Zhang
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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17
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Long-term blood pressure behavior and progression to end-stage renal disease in patients with immunoglobulin A nephropathy: a single-center observational study in Italy. J Hypertens 2021; 38:925-935. [PMID: 31977575 DOI: 10.1097/hjh.0000000000002354] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antihypertensive treatment by the use of RAAS inhibitors (RAAS-is) is of paramount importance in the management of slowly progressive IgA nephropathy (IgAN). With the aim of better understanding the relationship between BP behavior and progression, we looked at time-averaged SBP and time-averaged proteinuria and renal outcome in a single-center cohort of IgAN patients. METHODS Among 248 consecutive patients referred to the Clinic of Nephrology of San Martino Hospital from 1996 to 2018 for native renal biopsy with a diagnosis of IgAN, we retrospectively analyzed 145 with available data at baseline and during follow-up. All patients received Supportive Care, 39% were on RAAS-is alone, 45% plus steroids, and 16% plus steroids and immunosuppressors. Renal replacing treatment (RRT) was the primary endpoint. RESULTS During a mean follow-up of 67 ± 6 months, 23% of study patients (n = 33) progressed to RRT and 6% (n = 9) died. Patients who reached the renal endpoint, had lower baseline eGFR and higher proteinuria and proteinuria indexed at baseline. Moreover, they had higher TA-SBP (139 ± 17 vs. 130 ± 13, P = 0.0016). The incidence of RRT was higher in IgAN patients in the highest time-averaged SBP tertile as compared with the others (32 vs. 23 vs. 9%, χ 6.8, P = 0.033). After adjusting for baseline SBP, baseline and time-averaged proteinuria indexed, MEST-C score, and treatment, the association between TA-SBP and RRT persisted. CONCLUSION Time-averaged low BP values were independently associated to a decreased risk of renal progression in IgAN with no evidence of a J-curve relationship even at SBP levels below 125 mmHg.
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Treatment of IgA nephropathy in children: a land without KDIGO guidance. Pediatr Nephrol 2021; 36:491-496. [PMID: 32060820 DOI: 10.1007/s00467-020-04486-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/25/2019] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
IgA nephropathy (IgAN) in children is no longer considered a rare and benign disease but a nephritis with different presentations and various outcomes. The decision to initiate a treatment and the therapeutic choice depend on the individual risk of progression. The Kidney Disease: Improving Global Outcomes (KDIGO) clinical guidelines in 2012 considered that the risk factors for progression of IgAN were similar in both children and adults and suggested in some conditions to follow the adult schedules. In 2017 a KDIGO Controversies Conference on management and treatment of glomerular diseases decided not to include an update in children with IgAN since the level of evidence of treatments in children was too scarce. Children can follow the indications for adults as far as the disease is similar in the various ages. This review is aimed at discussing why the KDIGO guidelines are poorly suitable to treat children with IgAN, and there is a need to develop new prediction models for progression of IgAN in children to guide selection of the cases to be treated. The identification of different risk levels in children with IgAN may personalize the choice of available drugs and support the use of new targeted therapies.
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Maixnerova D, Tesar V. Emerging Modes of Treatment of IgA Nephropathy. Int J Mol Sci 2020; 21:E9064. [PMID: 33260613 PMCID: PMC7730306 DOI: 10.3390/ijms21239064] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 12/12/2022] Open
Abstract
IgA nephropathy is the most common primary glomerulonephritis with potentially serious outcome leading to end stage renal disease in 30 to 50% of patients within 20 to 30 years. Renal biopsy, which might be associated with risks of complications (bleeding and others), still remains the only reliable diagnostic tool for IgA nephropathy. Therefore, the search for non-invasive diagnostic and prognostic markers for detection of subclinical types of IgA nephropathy, evaluation of disease activity, and assessment of treatment effectiveness, is of utmost importance. In this review, we summarize treatment options for patients with IgA nephropathy including the drugs currently under evaluation in randomized control trials. An early initiation of immunosupressive regimens in patients with IgA nephropathy at risk of progression should result in the slowing down of the progression of renal function to end stage renal disease.
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Affiliation(s)
- Dita Maixnerova
- 1st Faculty of Medicine, General University Hospital, Department of Nephrology, Charles University, 128 08 Prague, Czech Republic;
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Lafayette RA, Rovin BH, Reich HN, Tumlin JA, Floege J, Barratt J. Safety, Tolerability and Efficacy of Narsoplimab, a Novel MASP-2 Inhibitor for the Treatment of IgA Nephropathy. Kidney Int Rep 2020; 5:2032-2041. [PMID: 33163724 PMCID: PMC7609886 DOI: 10.1016/j.ekir.2020.08.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/11/2020] [Accepted: 08/04/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Narsoplimab is a human monoclonal antibody against mannan-associated lectin-binding serine protease−2 (MASP-2). Now in a phase 3 study, narsoplimab was evaluated in a staged phase 2 study assessing safety and effectiveness in high-risk patients with IgA nephropathy (IgAN). Methods Substudy 1 was a single-arm open-label study of 12 weekly infusions and tapered corticosteroids, with 6 weeks of follow-up. In substudy 2, patients were randomized 1:1 to receive a course of treatment consisting of once-weekly narsoplimab or vehicle infusions for 12 weeks. After 6 weeks of follow-up, both substudy 2 groups could continue in an open-label extension, receiving 1 or more narsoplimab courses at the investigator’s discretion. Results The most commonly reported adverse events (AEs) included headache, upper respiratory infection, and fatigue. Most AEs were mild or moderate and transient. No treatment-related serious AEs were reported. All 4 patients who were enrolled in substudy 1 had reductions in 24-hour urine protein excretion (UPE) at week 18, ranging from 54% to 95% compared with baseline. In substudy 2, the vehicle and narsoplimab groups had similar proteinuria reductions at week 18. Eight patients (3 vehicle, 5 narsoplimab) continued in the dosing extension; all received narsoplimab. Median reduction in 24-hour UPE in these 8 patients was 61.4% at 31 to 54 weeks postbaseline. Estimated glomerular filtration rates (eGFR) remained stable in both substudies. Conclusion This interim analysis suggests that narsoplimab treatment is safe, is well tolerated, and may result in clinically meaningful reductions in proteinuria and stability of eGFR in high-risk patients with advanced IgAN.
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Affiliation(s)
- Richard A. Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California, USA
- Correspondence: Richard A. Lafayette, Division of Nephrology, Department of Medicine, Stanford University, Stanford, California 94305, USA.
| | - Brad H. Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Heather N. Reich
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James A. Tumlin
- NephroNet Clinical Research Consortium, Atlanta, Georgia, USA
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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Obrișcă B, Ștefan G, Gherghiceanu M, Mandache E, Ismail G, Stancu S, Boitan B, Ion O, Mircescu G. "Associated" or "Secondary" IgA nephropathy? An outcome analysis. PLoS One 2019; 14:e0221014. [PMID: 31398224 PMCID: PMC6688810 DOI: 10.1371/journal.pone.0221014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/30/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Whether differences in outcome between primary (pIgAN) and secondary IgA nephropathy (sIgAN) exist is uncertain. METHODS We conducted a retrospective, observational study that included all histologically diagnosed IgAN patients between 2010-2017 (N = 306), 248 with pIgAN and 58 with sIgAN. To obtain samples with similar risk of progression, sIgAN patients were grouped as liver disease and autoimmune/viral disease and propensity score matched to corresponding pIgAN samples. Univariate (Kaplan Meier) and multivariate time-dependent (Cox modelling) analyses were performed to identify predictors of the composite end-point (doubling of serum creatinine, end-stage kidney disease or death). RESULTS Of the whole cohort, 20% had sIgAN (6% alcoholic cirrhosis, 6% autoimmune disease and 8% viral infections). sIgAN patients were older, had more comorbidities, lower proteinuria and higher haematuria, but similar distribution in MESTC lesions and eGFR as those with pIgAN. They reached the end-point in similar proportions with those with pIgAN (43 vs. 30%; p = 0.09) but their mortality was higher (19 vs. 3%; p<0.0001). Both in unmatched (HR 0.80, 95%CI 0.42-1.52; p = 0.5) and matched samples (log-rank test: liver disease-IgAN vs. pIgAN, p = 0.1; autoimmune/viral-IgAN vs. pIgAN, p = 0.3), sIgAN was not predictive for end-point. In analyses restricted only to sIgAN, those with viral infections (HR, 10.98; 95% CI, 1.12-107.41; p = 0.03) and lower eGFR (HR, 0.94; 95%CI, 0.89-0.98; p = 0.007) had a worse prognosis. Immunosuppression did not influence outcome. CONCLUSIONS The differences in MESTC score and outcome between pIgAN and sIgAN seems to be minimal, suggesting that "associated" describes better than "secondary" the relationship among the two. Immunosuppression did not to influence outcome of sIgAN.
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Affiliation(s)
- Bogdan Obrișcă
- Nephrology Department, Fundeni Clinical Institute, Bucharest, Romania
- Nephrology Department,”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriel Ștefan
- Nephrology Department,”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- ”Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Mihaela Gherghiceanu
- Nephrology Department,”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- ”Victor Babes” National Institute of Pathology, Bucharest, Romania
| | - Eugen Mandache
- ”Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gener Ismail
- Nephrology Department, Fundeni Clinical Institute, Bucharest, Romania
- Nephrology Department,”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Simona Stancu
- Nephrology Department,”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- ”Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Bianca Boitan
- ”Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Oana Ion
- Nephrology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriel Mircescu
- Nephrology Department,”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- ”Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
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